Member Form– IndiaFirst Life Group Micro Insurance Plan UIN: 143N053V01

Client Id: SMS/RLE Branch Code: 0023 SMS/RLE LG Code:

DSA Code: Branch Code: 0023 Branch LG Code: 0023
160228C2‐7DC9‐
MSM Micro
MPH Name Transaction No. 4DD4‐BC5E‐ Date of Transaction 23‐05‐2022
Finance Limited
02A68AC4DF6E

Joint Life option: Primary Life Secondary Life (Life

Account: 5 5 1 2 3 4 3 8 0 4 3 3 3
(Life 1) 2)
Loan‐ Home/ Education/Vehicle/Personal/others, please specify : Micro Loan (Select " " for
applicable loan type)
New Loan: Old Loan: Old Loan Account Number:

Details of the Primary Life/Secondary Life

Primary Life Name:Mr/Ms/Mx

Gender: M DOB: 0 1 / 0 1 / 1 9 7 7
Shankarlal
Joint Life Name: Mr/Ms/Mx Gender: DOB:
Life 1 : Occupation Nature of duties
Life 2 : Occupation Nature of duties

Communication Address of the Member (Address to which policy document will be dispatched)

2 1 5 l a h i y a n a g a r i n d
o r e
I n d o r e
M A D H Y A P R A D E S H
Pin
452010 Mobile* 9 8 2 6 3 9 9 5 6 3
Code
Email ID

Insurance Details

Base Sum Assured 100000 Base Premium* 1032 Pay Mode Offline Policy Term(Months)
24
Premium Paying Term(Months) 24 Pay Frequency Single Annual Income
Life Cover Life Cover + Accidental Total Permanent Disability Life Cover + Critical Illness Life Cover +
Accidental Total Permanent Disability + Critical Illness
•For New Loan, Sum Assured and Plan Term will be as per sanctioned limit. •For Existing Loan, Sum Assured and Plan Term will be as per
outstanding balance as on date of premium debit
Premium paid from loan ( Yes/ No) Premium paid account number: 5 5 1 2 3 4 3
8 0 4 3 3 3
PAN: Sum Assured Type: Reducing Level Instalment Premium Amount 1032 Rate of
Interest
Accidental Total Permanent Disability + Critical Illness
•For New Loan, Sum Assured and Plan Term will be as per sanctioned limit. •For Existing Loan, Sum Assured and Plan Term will be as per
outstanding balance as on date of premium debit
Premium paid from loan ( Yes/ No) Premium paid account number: 5 5 1 2 3 4 3
8 0 4 3 3 3
PAN: Sum Assured Type: Reducing Level Instalment Premium Amount 1032 Rate of
Interest
(Form no. 60 if PAN is not available)
In case of Joint Life sum assured (%) Life 1________ Life 2________ Or 100% for both life (Policy terminates in case
of death of any one life)

Nominee/Appointee Details*

Nominee Percentage DOB of Relationship with Life Appointee Name (if Appointee Relationship with
Name Share Nominee Assured applicable) DOB Nominee
Dinesh 100.00 06‐05‐2002 SON

Health Declaration for Member (Non disclosures or misrepresentation of facts will highly impact
claim settlement)*

Primary Life: Feet inches: Weight in kg: Secondary Life: Feet inches: Weight in kg:

I hereby declare that I am in good health and I am not suffering or have not suffered from any illness / symptoms/
medical condition requiring medical treatment, medical investigation, surgery or hospitalization in past 3 years.I also
hereby declare that age mentioned in the proposal form is correct.

Declaration by the Member*

I understand and agree that the answer and statements made on this Health Declaration are full, complete and true
and will form the basis of the contract, which may arise. I / we further declare that I / we have not withheld any
material fact or information which may affect the decision of IndiaFirst Life Insurance Company Limited (Hereafter
called the “Company”) in underwriting the risk. In case of fraud, misrepresentation and suppression of material facts by
me/us, the policy contract/COI shall be treated in accordance with Sec 45 of Insurance Act,1938 as amended from time
to time. All material facts, which may influence the assessment of the risk have been disclosed.

I understand and agree that the maximum cover under the insurance scheme shall not exceed as agreed with
Master Policyholder, irrespective of any number of loan/Saving accounts held by me/us. I authorize the
Company to seek medical information from any doctor/hospital in respect of any matter relating to my
physical or mental health and I authorize the doctor/ hospital to give such information to the Company and/or
to their claims administrator or medical advisors. Further I also confirm that I have never participated nor
intend to participate in any hazardous sports or activity. I agree that in case of any medical request on my
proposal the risk will commence only on the date of acceptance of my proposal by the Company. I authorize
sharing with the Company, my personal/contact information to enable them to carry out their duties as the
Insurer. I also declare that all the information given by me is true, correct and complete or else the policy shall
stand cancelled.

Joint Life Signature:/Thumb impression*:

OTP Verified : 426488 Date: 23‐05‐2022 Date:

An OTP authentication number has been sent on your registered mobile number. By feeding in the said number in the
system, you hereby unconditionally and absolutely acknowledge and accept the Terms and Conditions of the policy in
its entirety and the same would create a legally binding agreement between the Company and You.

Authorisation for Settlement of Claim amount in favour of Master Policy Holder who is a Regulated
Entity

I authorise the Company to make the payment towards my Outstanding Loan Balance amount to Master Policyholder
system, you hereby unconditionally and absolutely acknowledge and accept the Terms and Conditions of the policy in
its entirety and the same would create a legally binding agreement between the Company and You.

Authorisation for Settlement of Claim amount in favour of Master Policy Holder who is a Regulated
Entity

I authorise the Company to make the payment towards my Outstanding Loan Balance amount to Master Policyholder
by deducting from claim proceeds payable on the happening of the contingent event covered by the Policy, in case the
policy is availed through a Regulated Entity as prescribed by the authority from time to time.

Joint Life Signature:/Thumb impression*:

OTP Verified : 426488 Date: 23‐05‐2022 Date:

An OTP authentication number has been sent on your registered mobile number. By feeding in the said number in the
system, you hereby unconditionally and absolutely acknowledge and accept the Terms and Conditions of the policy in
its entirety and the same would create a legally binding agreement between the Company and You.

Prohibition of Rebate: As per provisions of Section 41 of the Insurance Act, 1938 as amended from time to time. For
more details please refer to our website www.indiafirstlife.com

Fraud and Misrepresentation: As per provisions of Section 45 of the Insurance Act, 1938 as amended from
time to time. For more details please refer to our website www.indiafirstlife.com

Declaration by the person filling in the form (In case form is filled up / signed in a language different
from that of the Proposal Form)

1. Vernacular Declaration by the person filling in the form (In case form is filled up / signed in a language different from
that of the Proposal Form)
I do hereby state that I have read out and explained the contents of the proposal form and all other documents
incidental to availing the Insurance Policy from IndiaFirst Life Insurance Co.Ltd to the Member and he/ she have
understood the same. I declare that whatever I have stated herein above is true and correct to the best of my
knowledge and belief.

Name of the Declarant: Signature:

Relation with the Member:
Address of the Declarant:

I certify that the product applied for by me and the contents of the proposal form have been clearly explained
to me and I have fully understood them. I further certify that the replies in the proposal form have been
recorded as per the information provided by me.

Signature or thumb impression of the Member

2. In case the Member is illiterate, his/her thumb impression should be attested by a person of standing whose identity
can easily be established, but unconnected with the insurer and this declaration should be made by him.
“I hereby declare that I have fully explained the above questions and contents of the proposal form to the Member in
______________language, and that the Member has affixed the thumb impression above after fully understanding the
contents thereof.”

Name of the Declarant: Signature:

Relation with the Member:
Address of the Declarant:

Section 41 of Insurance Act 1938, as amended from time to time: 1) No person shall allow or offer to allow, either
directly or indirectly, as an inducement to any person, to take or renew or continue an insurance in respect of any kind
of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of
the premium shown on the Policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate,
except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer. 2) Any
person making default in complying with the provisions of this section shall be liable for a penalty which may extend to
Section 41 of Insurance Act 1938, as amended from time to time: 1) No person shall allow or offer to allow, either
directly or indirectly, as an inducement to any person, to take or renew or continue an insurance in respect of any kind
of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of
the premium shown on the Policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate,
except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer. 2) Any
person making default in complying with the provisions of this section shall be liable for a penalty which may extend to
ten lakh rupees.

Extract of Section 45 of the Insurance Act, 1938, as amended from time to time: No policy of life insurance shall be
called into question on any ground whatsoever after the expiry of three years from the date of policy.A policy of life
insurance may be called into question at anytime within three years from the date of policy, on the ground of fraud or
on the ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was
incorrectly made in the proposal or other document on the basis of which the policy was issued or revived or rider
issued.The insurer shall have to communicate in writing to the insured or legal representatives or nominees or
assignees of the insured, the grounds and materials on which such decision is based.No insurer shall repudiate a life
insurance policy on the ground of fraud if the insured can prove that the misstatement or suppression of material fact
was true to the best of his knowledge and belief or that there was no deliberate intention to suppress the fact or that
such misstatement or suppression are within the knowledge of the insurer. In case of fraud, the onus of disproving lies
upon the beneficiaries, in case the policyholder is not alive.In case of repudiation of the policy on the ground of
misstatement or suppression of a material fact and not on the grounds of fraud, the premiums collected on the policy
till the date of repudiation shall be paid. Nothing in this section shall prevent the insurer from calling for proof of age
at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms
of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.
For complete details of the section and the definition of "date of policy", please refer Section 45 of the Insurance Act,
1938, as amended from time to time.

IndiaFirst Life Insurance Company Ltd.,
12th and 13th Floor, North[C] Wing, Tower 4, Nesco IT
Park, Nesco Center,
Western Express Highway, Goregaon(East), Mumbai –
400063,
IRDAI Regd.No. 143 I CIN: U66010MH2008PLC183679.
Tel: +91 22 6165 8700 Fax: +91 22 6857 0600 Toll
Free:1800‐209‐8700
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
‐‐‐‐‐‐‐‐‐‐
E‐mail: customer.first@indiafirstlife.com
Website:www.indiafirstlife.com